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1. Shoulder

2. Knee/ACL

3. Hip

4. Neck

5. Low Back

6. Heel

7. Ankle

8. Achilles

Shoulder Pain:Adhesive Capsulitis

Dani Goettl, Mikaila Foster, Caroline

Kreuz, Chandler McCrury, Katie

Mullen, Tina Stough

Summary of CPG: Shoulder Pain and

Mobility Deficits: Adhesive Capsulitis

Clinical Course ● Occurs as a continuum with stages

of progression of pain and mobility ○ At 12 to 18 months. Mild to moderate

mobility deficits and pain may persist, without disability

Diagnosis● 3 components

○ Medical screening○ Differential evaluation ○ Tissue irritability & ability to handle

stress

Risk Factors● Diabete mellitus ● Thyroid disease● Most prevalent in individuals…

○ 40 to 60 of age○ Female ○ Have had previous episode of A.C.

Differential Diagnosis● Sprain & strain of joint/dislocation ● Rotator cuff syndrome

○ Tendinopathy● And others

CPG Continued

Intervention Recommendations

Intra-articular corticosteroid injections + shoulder mobility and stretching

Patient Education Describe natural course of disease

Promote activity modifications for painless and functional ROM

Match stretch intensity to patient’s level of irritability

Joint Mobilizations Differ depending on irritability level; refer to CPG

Outcome Measures: Before & After treatment

DASH, SPADI, ASES

Other Articles1) Bang, M. D., & Deyle, G. D. (2000). Comparison of supervised exercise with and without manual physical

therapy for patients with shoulder impingement syndrome. Journal of Orthopaedic & Sports Physical Therapy,

30(3), 126-137.

2) Diercks, R. L., & Stevens, M. (2004). Gentle thawing of the frozen shoulder: a prospective study of supervised

neglect versus intensive physical therapy in seventy-seven patients with frozen shoulder syndrome followed

up for two years. Journal of Shoulder and Elbow Surgery, 13(5), 499-502.

3) Donatelli, R., Ruivo, R. M., Thurner, M., & Ibrahim, M. I. (2014). New concepts in restoring shoulder elevation in

a stiff and painful shoulder patient. Physical Therapy in Sport, 15(1), 3-14.

4) Kuijpers, T., van der Windt, D. A., Boeke, A. J. P., Twisk, J. W., Vergouwe, Y., Bouter, L. M., & van der Heijden, G.

J. (2006). Clinical prediction rules for the prognosis of shoulder pain in general practice. Pain, 120(3), 276-

285.

5) Thelen, M. D., Dauber, J. A., & Stoneman, P. D. (2008). The clinical efficacy of kinesio tape for shoulder pain: a

randomized, double-blinded, clinical trial. Journal of orthopaedic & sports physical therapy, 38(7), 389-395.

Luke Van Every

“The Shoulder Guy”

Practicehttp://www.shoulderguyphysiotherapy.com.au/

Bloghttp://www.theshoulderguy.com/

Podcast

“The Shoulder Guy |Simple, Practical, No B.S. Shoulder Physiotherapy Advice,

Training and Community”

Follow @TheShoulderGuy

“You need evidence based advice-Not opinions”

@SPTSShoulderSIG

Take Home Messages

1. Frozen Shoulder: an idiopathic condition where the shoulder joint

capsule thickens and tightens causing pain and restriction of motion.

2. Since this is an idiopathic condition, it is important to explain to the

patient what exactly is going on with their shoulder, as well as the 4

stages of the condition they will experience .

3. Most important things we can do as a PT:

a. Patient education

b. ROM/stretching techniques

c. Ultrasound to aid in pain management

Knee Pain and Mobility Impairments:

Meniscal and Articular Cartilage Lesions

Meniscal injuries are the second most common

injury to the knee

Incidence of 12-14%

Accounts for 10-20% of all orthopedic surgeries

Risk Factors

Meniscus

Age

Time from initial injury

High intensity athlete

ACL Surgery → Knee Laxity

Articular Cartilage

● Age

● Presence of meniscal tear

● Time from initial injury (ACL)

Clinical Presentation

Knee pain

Mobility impairments

Effusion (6-24 hrs post injury)

Differential diagnosis

Mechanism/Classification:Twisting injury, tearing sensation

History of “catching” or “locking”

Pain with forced hyperextension and maximum flexion

Pain or audible click with McMurray’s maneuver

Joint line tenderness

Discomfort during the Thessaly Test

Outcome Measures

The Knee Injury and Osteoarthritis Outcome Score

(KOOS) I

Self reported assessment for sports injuries in adolescents

The Knee Outcome Survey ADL Scale (KOS-ADLS) I

Self reported measure of functional limitations and impairments

during ADL’s

Ottawa Knee Rule

Used for determining if imaging is necessary

Tests and Measures:

Thessaly

McMurray’s

Bulge Sign

Knee Joint Line Tenderness

Knee AROM/PROM

Meniscal Pathology Composite Score

Interventions

Neuromuscular Electrical Stimulation

(NMES)

Moderate evidence supports w/ACL injury

leading to meniscal/chondral lesions:

safely load muscles for strength

adaptation w/minimal stress damage to

tissues

Limited research for quad strengthening post-

isolated meniscal/chondral lesions

Therapeutic Exercises

Strength training/Functional exercise

Quad/Hamstring strength

Quads endurance

Functional performance

Progressive resistive exercises = safe

loading w/minimal stress damage to

tissues

Multimodal Functional Exercise Program

Isokinetic muscle strengthening

Take Home Points

1. Diagnosing severity of injury based on risk factors and clinical presentation

is important for deciding course of action during clinical care.

2. Outcome measures and tests (KOOS, Thessaly, Bulge Sign, Etc) should

be appropriately used in order to measure improvement and quantify

progress.

3. Several different interventions show potential for therapeutic value, but the

evidence supports therapeutic exercise and neuromuscular electrical

stimulation as the strongest interventions for rehabilitation.

WITH MUCH LOVE!

DION

JENNA

KATE

KEVIN

LAUREN

NICK

Josptorg. 2016. Available at: http://www.jospt.org/doi/pdf/10.2519/jospt.2010.0304. Accessed June 12, 2016.

Hip Pain and Mobility Deficits-

Hip Osteoarthritis

By Hannah, Danielle, Esther, Kelcii, Jordon, Alaitia

NonArthritic Hip Joint Pain: A CPG

➢ Diagnosis/Classification: Weak Evidence

○ Clinical Findings: anterolateral hip pain or generalized hip pain

that is reproduced with FADIR or FABER test that is consistent

with imaging findings

➢ Differential Diagnosis: Expert Opinion

➢ Interventions: Expert Opinion

○ Patient education and counseling

○ Manual therapy

○ Therapeutic exercises and activities

○ Neuromuscular Re-education

JOSPT, Enseki K, Harris-Hayes M, White DM,

et al.

Diagnosing Osteoarthritis of the Hip

❏ JOSPT CPR (2008)

Sutlive T, Lopez H, Schnitker D, et al

❏ 5 predictor variables with 4 out of 5 being highest likelihood of having OA

❏ Compared predictor variables to Gold Standard: Radiographs

❏ JOSPT CPG (2009)

Cibulka MT, White DM, Woehrle J, et al

❏ CPR Level II evidence

❏ Grade A high predictors of presence of hip OA

❏ Moderate anteriolateral hip pain during wt. bearing

❏ Over 50

❏ Morning stiffness less than an hour

❏ Limited IR and flexion by more than 15 degrees

Outcome

MeasuresPatient Questionnaires

● WOMAC

● LEFS

● Harris Hip Score

Activity Limitation

and Participation

Restriction Measures

6 min walk test

Self-paced walk test

Stair measure

TUG

Outcomes- Physical Impairment Measures

● Passive Hip IR & ER & Hip Flexion-mobility

● Hip Abductor Muscles Strength Test- strength

● The FABER (Patrick’s Test)-irritability

● The Scour Test -irritability

Interventions1. Patient Education

● Activity modification

● Exercise

● Weight Reduction

● Unloading Joints

2. Functional Gait & Balance Training

● AD use

● Improve function w/ WBing activities (OA)

3. Manual Therapy

● Short-term pain relief

● Hip mobility (OA)

● Hip function (OA)

4. Exercise Therapy

● ROM/Flexibility○ Low intensity, controlled movements

○ Emphasis on iliopsoas, rectus femoris, hip adductors

○ Heat then stretch for 15-30 sec (5-10x/day at least 3x/week)

● Muscle Strengthening○ Progressive resistive exercises

○ Frequency, intensity, duration, exercise type specific to individual

● Aerobic Conditioning/Endurance○ Walking, Aquatic exercise

○ Workload at 60-80% max capacity & sustained duration of at least 20

minutes

Cibulka MT, White DM, Woehrle J, et al

Neck PainChris Campbell, Bethany Hightower, Lexi

Okurily, Sara Patterson, Eddie Smith

Aims . . . 1. Correct classification and diagnosis of mechanical neck pain

2. Appropriate interventions for patients based on classification

3. Influential Peoplea. John Childs, PT, PhD

b. Joshua A. Cleland, PT, PhD, OCS, FAAOMPT

c. Jan L. Hoving, PT, PhD

Summary of RecommendationsPathoanatomical Features

Risk FactorsAge > 40

Coexisting LBP

Hx of neck pain

Classification/Diagnosis

ExaminationOutcome Measures

Neck Disability Index

Patient-Specific Functional Scale

InterventionsManipulation

Education

Exercise

Childs, JOSPT. 2008

CPG Classification

Childs, JOSPT. 2008

Fritz, Physical Therapy. 2007

CPG Interventions● Patient Education and Counseling

○ Whiplash patients

Stretching Exercises

Cervical Manipulation and Exercises

Reduce neck pain and headaches

Reduces pain and disability in pts with neck and arm pain

Upper Quarter and Nerve Mobilization Procedures

Traction

Thoracic Mobilization/Manipulation

Childs, JOSPT. 2008

Clinical Prediction Rules

Treating Mechanical Neck Pain with

Thoracic Spine Thrust Manipulation

6 Variables

Symptoms < 30 days (Strongest Predictor)

No symptoms distal to shoulder

Looking up doesn’t aggravate symptoms

FABQPA score <12

Diminished Upper Thoracic Spine Kyphosis

Cervical Extension ROM < 30 degrees

Grade C (Cerv. Manip - Grade A)Cleland, Joshua A. et al.

JAPTA. 2007

CPG OverviewNeck pain with…

Mobility deficit

Headache

Movement

Radiating pain

➢Best Treatments:

○ Exercise

○ Spinal Manipulation

○ Patient Education

Childs, JOSPT. 2008

Treatment Guidelines for Patients with Low Back Pain

Goal: Prevent Recurrences and the transition to Chronic LBP.

Rule out other Dx, figure out pt. limitations, classify LBP.

Treat the patient with the recommended method based on classification/pt. limitations.

Why and How?: 3 things to remember

Best evidence deemphasize the importance of IDingspecific anatomical lesions.

Interventions based on sub-group classification work best.

How to Classify? Use history, outcome tools, location, response to pain,

description of pain (in other words everything we did in diff diagnosis). Acute, Sub-Acute, Chronic Mobility of joints Movement coordination impairments Referred or Radicular Cognitive or Affective Components Generalized Pain or Localized Pain

Classifying LBP

Trunk Coordination, Strengthening, and Endurance Exercises: sub-acute and chronic low back pain with movement coordination impairments and in patients post lumbar microdiscectomy (SE).

Thrust manipulative procedures: mobility deficits and acute low back and back-related buttock or thigh pain (SE)

Repeated movements, exercises, or procedures to promote centralization: acute LBP w/ referred pain into LE (SE)

Interventions

Traction: nerve root compression along with peripheralization of symptoms or a positive crossed straight leg raise (Preliminary Evidence).

Lower Quarter Nerve Mobilization: subacute and chronic low back pain and radiating pain (WE).

Flexion Exercise: older pt. w/ chronic LBP w/ radiating pain. combined w/ other Tx (WE).

Patient Education and Counseling: Focus on positives not the negatives (ME).

Interventions

Progressive Endurance Exercise and Fitness Activities:

Chronic LPB w/o generalized pain – moderate to high intensity exercise

Chronic LPB Generalized Pain – progressive low intensity sub-max fitness and endurance activities (SE)

Interventions

Delitto A, George S, Van Dillan L, et al. Low Back Pain. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports Physical Therapy. 2012;42(4):381-381. doi:10.2519/jospt.2012.0503.

Reference

Ankle Instability

Brett, Lauren, Cara, Casey,

Kelsey, Marissa

CPG outlineRisk Factors- Acute Lateral Ankle Sprain

History of previous ankle sprain

Do not properly warm up with static stretching/dynamic movement before activity

Abnormal DF ROM

No use of external support

No participation in balance/proprioceptive prevention programs with history of previous injury

Risk Factors- Ankle Instability

No use of external support

Increased talar curvature

No participation in balance/proprioceptive prevention programs with history of previous injury

Diagnosis

Cumberland Ankle Instability Tool (CAIT)

Ankle Sprain Grades

Graded I-III

Martin RL, Davenport TE, Paulseth S, Wukich DK, Godges JJ. Ankle

Stability and Movement Coordination Impairments: Ankle Ligament

Sprains. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports

Physical Therapy. 2013;43(9). doi:10.2519/jospt.2013.0305.

CPG outline cont’d

Two Stages of InterventionTherEx

Single limb balance activities using unstable surfaces

Manual Therapy

Graded joint mobilizations (with or without movement)

Graded joint manipulations

Activity Training

Weight-bearing functional exercises

Sport-specific activity

Modalities

Cryotherapy, Diathermy, Electrotherapy, Laser Therapy

Outcome MeasuresLEFS, Foot and Ankle Ability Measure Martin RL, Davenport TE, Paulseth S, Wukich DK, Godges JJ. Ankle

Stability and Movement Coordination Impairments: Ankle Ligament

Sprains. J Orthop Sports Phys Ther Journal of Orthopaedic & Sports

Physical Therapy. 2013;43(9). doi:10.2519/jospt.2013.0305.

Relevant Articles Take home points:

1. Exercise therapy is effective in the prevention of recurrent ankle sprains.

Manual mobilization has an initial effect on dorsiflexion ROM. (Van der

Wees, 2006)

2. Postural control and and functional limitations exist in people with chronic

ankle instability. Comprehensive rehabilitation (including ROM, strength

training, neuromuscular control, and functional tasks) appears to improve

these functional limitations. (Hale, 2007)

3. Deficits in passive movement sense and anatomic stability are greater

concerns than strength deficits when managing the ankle with functional

instability. (Lentell, 1995)

Relevant articles cont’d

Take home points:

4. Training on a wobble board early after a primary grade 2 ankle sprain is

effective in reducing residual symptoms from the sprain. (Wester, 1996)

5. Based on the results of this study, mechanical instability of the talocrural

joint is frequently absent in people with functional ankle instability. UBE (uni-

axial balance evaluator) testing is consistent with the theory that

proprioceptive deficits cause functional instability. (Ryan, 1994)

Influential personsJay Hertel PhD, ATC

University of Virginia, Charlottesville

Associate professor of Kinesiology

Co-director of the Exercise and Sports Injury

Laboratory

273 publications; 6,829 citations

Eamonn Delahunt PhD, BsCUniversity College, Dublin

95 publications; 1,402 citations

Co-Authored in British Journal of Sports

Medicine2016 consensus statement of the International Ankle

Consortium: prevalence, impact and long-term

consequences of lateral ankle sprains

What to Remember1. Diagnosis

Cumberland Ankle Instability Tool

2. ExaminationAssessment of impairment of body function including:

Measures of ankle swelling

Ankle ROM

Talar translation and inversion

Single-leg balance

3. Intervention- Two StagesImmobilization→ AD → weight-bearing

Active/passive STM

Graded joint mobilizations/manipulations with movement

Activity specific training

Achilles

TendinopathyAllie, Matt, Mitchell, Kameron,

Stephanie, Steven

Background, Prevalence, and

Population● Overuse Injury of the Achilles Tendon

○ More often doesn’t involve inflammatory cells so shouldn’t be termed “tendinosis” or “tendinitis”

○ Ranked among the most reported overuse injuries in literature

○ Mid-portion

● Annual Incidence- 7-9% in runners

● Mean age 30-50 yrs old

● Males>Females

● Majority of those affected are those engaged in activity at recreational or

competitive level○ Occurs most often during training rather than during competitive events

○ Runners are most often reported but have occurred in wide array of sports

Carcia CR, Martin RL, Houck J, Wukich DK, Altman RD, Curwin S, Delitto A, DeWitt J, Fearon H, Ferland A, MacDermid J. Achilles Pain, Stiffness, and Muscle Power Deficits: Achilles Tendinitis: Clinical Practice Guidelines Linked to the

International Classification of Functioning, Disability, and Health from the Orthopaedic Section of the American Physical Therapy Association. Journal of Orthopaedic & Sports Physical Therapy. 2010 Sep;40(9):A1-26.

1. Who has it?

Intrinsic and Extrinsic Risk Factors

(Level B)

• Increased/decreased dorsiflexion ROM (I)

• Increased/decreased subtalar ROM (II)

• Decreased plantar flexion strength (II)

• Increased pronation/calcaneal inversion/forefoot varus (II)

• Abnormal tendon structure - found by ultrasound (II)

• Comorbidities: obesity, HBP, high cholesterol, diabetes (III)

• Training errors, environmental factors, faulty equipment (II)



Diagnosis, Classification, and

Prognosis (Level C)No formally accepted classification system has been accepted

What then is used in diagnosis?Positive achilles tendon palpation test (tenderness 2-6 cm proximal to insertion) (II)

Decreased plantar flexor strength/endurance (II)

Positive arc sign (II)

Positive Royal London Hospital Test (II)

Stiffness during WBing and after sleep (V)

Intermittent pain during activity/exercise (V)

Pain stiffness starting exercise (V)

Favorable prognosis w/ nonoperative treatment71% - 100% return to prior level of physical activity

Conservative and operative prognosis worse in non athletic population



2. What do we measure?

Outcome MeasuresThe Victorian Institute of Sport Assessment (VISA-A) (Level I)

Developed specifically to assess severity of achilles tendinopathy Not designed to be diagnostic tool

Consists of 8 items: assesses stiffness, pain, and function

r=0.90 for both intra- and inter-rater reliability (test-retest r=0.8)

The Foot and Ankle Ability Measure (FAAM) (Level I)

Region specific and assesses activity and participation limitations for general

MSK foot and ankle disordersConsists of 21-item ADL subscale and separately scored 8-item Sports subscale

r=0.89, r=0.87 test-retest ADL and sports subscale respectively



3. How do we treat?

Interventions- Eccentric Loading (Level A)

Eccentric loading program shown to decrease pain and improve function in pts

with midportion achilles tendinopathy

3 studies with level I evidence and 11 studies with level II evidence

Alfredson et al. protocol:Unilateral eccentric heel raises w/ no concentric component (unaffected LE returns affected side

back to starting position)

Slow and controlled movements with moderate but not disabling pain

3 sets of 15, both knee extended and flexed, 2x daily for 12 weeks

External weight added with backpack if needed



Interventions - Low Level Laser

Therapy (LLLT) and Iontophoresis

(Level B)LLLT utilizes a machine that uses low power lasers to stimulate tissue and

encourage function of the cellsExperimental group (n=20) treated w/ LLLT and control

group (n=20) treated w/ placebo 12x over 8 weeks

Both followed same eccentric loading protocol following treatment

Intervention group perceived less pain at 4,8,12 weeks and improved

in secondary measures (palpation tenderness, stiffness, dorsiflexion AROM, crepitation)

Iontophoresis on achilles tendinopathyExperiment group (n=14) w/ dexamethasone and control (n=11) w/ saline for 4x over 2 weeks.

Afterwards, both received same 10 week rehab protocol (protocol not mentioned)

Experimental group had less pain with walking, post-activity, and walking up/down stairs

Neeter C, Thomee R, Silbernagel KG, Thomee P, Karlsson J. Iontophoresis with or without dexamethazone in the treatment of

acute Achilles tendon pain. Scand J Med Sci Sports. 2003;13:376-382.

Stergioulas A, Stergioula M, Aarskog R, Lopes-Martins RA, Bjordal JM. Effects of low-level laser therapy and eccentric

exercises in the treatment of recreational athletes with chronic achilles tendinopathy. Am J Sports Med. 2008;36:881-887.

http://dx.doi.org/10.1177/0363546507312165

http://dx.doi.org/10.1177/0363546507312165

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